Notice of Privacy Practices
For the office of
Stapleton Dentistry
Paula M. Stapleton, DDS
THIS NOTICE DESCRIBES
HOW MEDICAL INFORMATION
ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
Uses and disclosures to carry
out treatment, payment, and
health care operations
Treatment This practice may
use or disclose your protected
health information in consultation
between health care providers
relating to your treatment or for
your referral to another health
care provider for your treatment.
Payment This practice may use
or disclose your protected health
information for billing, claims
management, collection activities,
or obtaining
payment.
Health care Operation- This
practice may use or disclose your
protected health information for
reviewing the competence or
qualifications of health care
professionals, or for conducting
training programs in which
students, trainees, or
practitioners participate. This
practice may use or disclose your
protected health information for
accreditation, certification,
licensing, or credentialing
activities.
This practice may use or disclose
protected health information to
remind you of your appointment,
to give you information about
treatment alternatives, or other
health related benefits or
services. We may also use
information about your
demographic and dates of
treatment in order to contact you
for our fundraising activities. If
you do not want the information
about treatment alternatives,
other health related benefits,
services, or fundraising, you may
notify our office and you will
receive no further information
Tel: (919) 851-6161
Authorized Disclosures- For
any other use or disclosure you
wish us to make, you can give us
a written, valid authorization.
Your authorization must have
specific instructions for the use
and disclosure you want us to
make. You will have the right to
revoke the authorization in writing
at any time before the information
is used or disclosed.
Uses or disclosures requiring
an opportunity for the
individual to agree or object
For disclosures to others
involved with your health care or
payment, we will inform you in
advance and give you the
opportunity to agree or object.
These disclosures will be limited
to the information necessary to
help with your health care or
payment. These disclosures
will only be made if you do not
object.
Uses and disclosures for
which an authorization or
opportunity to agree or object
is not required
The following uses or
disclosures do not require an
authorization or the opportunity
for you to agree or object.
Uses and disclosures required
by law-This practice may use or
disclose protected health
information to the extent required
by law. The use or disclosure will
comply with and be limited to the
relevant requirements of such
law.
Uses and disclosures for
public health activities-This
practice may use or disclose
protected health information for
the purpose of preventing or
controlling disease, injury, or
disability, including, but not
limited to, the reporting of
disease, injury, and vital events
such as birth or death.
Disclosures about victims of
abuse, neglect or domestic
violence
This practice may disclose
protected health information
about an individual whom this
practice reasonably believes to
be a victim of abuse, neglect, or
domestic violence.
8204 Tryon Woods Dr. Suite 102, Cary, NC 27518
Uses and disclosures for
health oversight activities-This
practice may disclose protected
health information to a health
oversight agency for oversight
activities authorized by law,
including audits, civil,
administrative, or criminal
investigations, inspections,
licensure, or disciplinary actions.
Disclosures for judicial and
administrative proceedingsThis practice may,in response
to an order of a court RU
administrative tribunal, provide
only the protected health
information expressly authorized
by such order or a subpoena.
Disclosures for law
enforcement purposes This
practice may disclose protected
health information as required by
law including laws that require
the reporting of certain types of
wounds or other physical injuries.
Uses and disclosures about
decedents- This practice may
disclose protected health
information to a coroner or
medical examiner for the purpose
of identifying a deceased person,
determining a cause of death, or
other duties as authorized by law.
We may disclose protected
health information to a funeral
director, as authorized by law, to
carry out their duties. This
disclosure will be made in
reasonable anticipation of death.
Uses and disclosures for
cadaveric organ, eye or tissue
donation purposes This
practice may use or disclose
protected health information to
organ procurement organizations
or other entities engaged in the
procurement, banking, or
transplantation of cadaveric
organs, eyes, or tissue for the
purpose of facilitating organ, eye
or tissue donation and
transplantation.
Uses and disclosures for
research purposes- This
practice may use or disclose
protected health information for
research, when the research has
been approved by an institutional
review board or privacy board, to
protect your protected health
information.
Uses and disclosures to avert
a serious threat to health or
safety This practice may,
consistent with applicable law
and standards of ethical conduct,
use or disclose protected health
information, in good faith, if we
believe the use or disclosure is
www.stapletondentistry.com
necessary to prevent or lessen a
serious and imminent threat to
the health or safety of a person or
the public.
Uses and disclosures for
specialized government-This
practice may use and disclose
the protected health information
of individuals who are Armed
Forces personnel for activities
deemed necessary by
appropriate military command
authorities to assure the proper
execution of the military mission,
if the appropriate military
authority has published by notice
in the Federal Register.
Disclosures for workers'
compensation-This practice may
disclose protected health
information as authorized by and
to the extent necessary, to
comply with laws relating to
workers' compensation or other
similar programs, established by
law, that provide benefits for
work-related injuries or illness
without regard to fault.
Patient rights under HIPAA
The following information
describes your rights under the
HIPAA Privacy standard. This
practice requires that all requests
for the various rights be made in
writing. You should be aware
that there may be some
situations when there could be
limitations placed on your rights.
We are required to permit you to
request these rights, but we are
not required to agree to your
request.
Right of an individual to
request restriction of uses and
disclosures
This practice will permit an
individual to request that we
restrict uses or disclosures of
protected health information
about the individual to carry out
treatment, payment, or health
care operations.
Confidential communication
requirements
This practice will permit an
individual to request and will
accommodate reasonable
requests to receive
communications of protected
health information from our
practice by alternative means or
at an alternative location.
Access of individuals to
protected health
information
Tel: (919) 851-6161
An individual has a right of
access to inspect and obtain a
copy of protected health
information about the individual in
a designated record set except
as prohibited by state or federal
law. As permitted by state and
federal law, we may charge you a
reasonable cost based fee for a
copy of your record. Questions
about the fee should be
addressed to our Privacy Officer
at this phone number at the end
of this document.
Amendment of
protected health
information
An individual has the right to ask
to have this practice amend
protected health information or a
record about the individual in a
designated record set for as long
as the protected health
information is maintained in the
designated record set.
Accounting of disclosures of
protected health information
An individual has a right to
receive an accounting of
disclosures of protected health
information made by this practice
in the past six years but not
before April 14, 2003. The
accounting will not include
disclosures made for treatment,
payment, or operations, as well
as authorized disclosures or
disclosures made for which you
had an opportunity to agree or
object. You may receive one free
accounting in a 12 month period.
There will a reasonable cost
based fee for additional requests.
notice. We reserve the right to
change the terms of our notice
and to make the new notice
provisions effective for all
protected health information that
we maintain.
Complaints
If at any time you feel we have
violated your privacy rights,
please contact our Privacy Officer
or the Secretary of Health and
Human ServicesThis practice
will not retaliate against any
individual for filing a complaint.
Contact
You have the right to file a
complaint with our Privacy Officer
at the address and phone
number at the top of this notice,
or with the Office Of Civil Rights,
US Department of Health and
Human Services, 61 Forsyth St.,
SW, Suite 3B70, Atlanta, GA
30323.
Copy of this notice
You have a right to a copy of this
notice. Even if you agreed to
receive an electronic copy, you
may request and receive a paper
copy.
Our Duties
This practice is required by law to
maintain the privacy of protected
health information and to provide
individuals with notice of our legal
duties and privacy practices with
respect to protected health
information.
This practice is required to abide
by the terms of the notice
currently in effect.
This practice is required to notify
you of any change in a privacy
practice that is described in the
notice to protected health
information that we created or
received prior to issuing a revised
8204 Tryon Woods Dr. Suite 102, Cary, NC 27518
www.stapletondentistry.com
Healthy Smiles. Healthy Family. Happy Life.
Acknowledgement of Receipt of Notice of Privacy Practices
Paula Stapleton, DDS
8204 Tryon Woods Dr. Suite 102
Cary, NC 27518
(919) 851-6161
Patient Name:
Patient Phone #:
I hereby acknowledge that I have received the Notice of Privacy Practices for the
above office.
________________________________________________________________
Signature: Patient’s Name / Personal Representative (as defined by HIPAA)
Date
________________________________________________________________
Description of Personal Representation and please attach copy of documentation.
Documentation of “Good Faith” Attempt to get acknowledgement
signature.

Document presented to patient, but patient refused to sign
acknowledgement.

Patient presented with an emergency situation and there was no time to
give the Notice or receive a signature. Attempt to get give the Notice, and
get any acknowledgement will be handled as soon as possible.

Documentation was presented to the patient but a communication failure
prevented us from receiving the acknowledgement.

The documentation was mailed to the patient but never returned to us.

Other ______________________________________________________
___________________________________________________________
Employee preparing document
Date
________________________________________________________________
Employee signature _______________________________________________
Tel: (919) 851-6161
8204 Tryon Woods Dr. Suite 102, Cary, NC 27518
www.stapletondentistry.com